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Executive Positions with Managed Care Organizations - Southern California and Texas
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espsonia@pacbell.net
Contact: Sonia Varian
T 818.707.7118
VICE PRESIDENT OF
MEDICAL AFFAIRS - TEXAS
Responsible for the organization’s clinical vision, philosophy and strategy.
Oversee the medical management and quality improvement programs support of the
organization’s strategic plan. Develop and present clinical vision to various
public stakeholders both locally and nationally. Oversee and support the medical
management structure, assuring high quality care and compliance with regulatory
and accreditation requirements. Administrative oversight and accountability for
the quality improvement department.
Knowledge/Experience:
Requires an unrestricted licensed Medical Doctor or Doctor of Osteopathy, board
certification in Psychiatry required. Previous experience as a senior level
medical position with a managed behavioral health organization is required.
Prior experience as a Medical Director for an MBHO with Medicaid/Medicare
programs is preferred. Experience treating or managing care for a culturally
diverse population preferred. Experience with quality improvement for an
organization as well as knowledge of certification/accreditation standards such
as URAC, NCQA is preferred. Course work in the areas of Health Administration,
Health Financing, Insurance, and/or Personnel Management is a plus.
V.P. SALES AND BUSINESS
DEVELOPMENT - TEXAS
Oversee national Sales and Business Development
Experience with sales and business development activities in Medicaid/Medicare
or public sector programs preferred. Master’s degree preferred. Behavioral
Health experience is preferred
Requires a Bachelor's degree in Business Administration, Public
Health/Administration or equivalent. Experience in healthcare sales/business
development or with complex, consultative sales of programs/solutions to
government entities.
Responsible for developing new market initiatives, assessing new markets, analyzing business opportunities and driving sales process to expand the business unit.
Develop and oversee plan for government relations support as it relates to program strategies and market introductions; manage relationships with government officials to advance the company’s position.
MEDICAL DIRECTOR -
HEALTH PLAN - SO. CALIFORNIA
Under the supervision of the Associate Chief of Managed Care, the Medical
Director, Managed Care, is responsible for the appropriateness and quality of
medical care. The Medical Director shall develop processes for medical reviews
for coverage determinations for medical services and participate in the
grievance and appeals process. The Medical Director shall provide guidance to
health plan quality improvement, utilization management, as well as continuous
measuring, monitoring and improvement of the health delivery system for plan
members. Participate in strategic planning efforts for the Managed Care Division
with respect to medical aspect of the health plan.
Maintain knowledge in general medicine and disease specific national guidelines.
DM utilization review and care management programs.
Assure members receive quality, medically necessary care that balances individual need with cost effectiveness.
MANAGER OF CLAIMS -
HEALTH PLAN - SO. CALIFORNIA
Align the daily operations of the Claims Department with the strategic direction
of the organization.
Clearly define department goals and focus staff upon these goals.
Build supportive, team-oriented environment for the staff through embodying a
sense of empowerment, demonstrating positive thinking and establishing common
goals and interdependence with employees.
Manage corrective actions in accordance with Quality Management or Compliance
Department instructions, and Federal or State guidelines and expectations.
Review all department operating procedures & policies on at least an annual
basis & recommend any necessary revisions or additions as necessary.
Draft operating procedures, policies & procedures for review & approval by
appropriate Committees, Management.
Supervises Claims Examiner(s), Senior Claims Examiners, temporary Claims staff &
administrative support staff. Carries out supervisory responsibilities in
accordance with policies and applicable laws.
Minimum one (1) year experience with supervisory position in a Health Plan
claims department.
Proven experience in customer service.
Thorough knowledge of claim procedures, policies, terminology, federal/state
statutes & guidelines, including extensive knowledge of Medicare & Medicaid
payment methodology.
The ability to operate PC or network based claims software programs, proficiency
in Microsoft Word & Excel required.
Experience with EZ-CAP Claims Adjudication software preferred.
Advanced technical proficiency with medical terminology, all standard medical
coding guidelines (CPT, HCPCS, ICD-9, ICD-10 when applicable, Medicaid Local
Codes, Modifier Codes) & all Medicare & Medicaid Payment Guidelines or general
claims payment guidelines & practices including Medicare DRG based Prospective
Payment systems (PPS), Medicare Part B vs. Part D billing & payment guidelines,
Medicare Ambulatory Payment Classification PPS, Medicare Home Health PPS,
Medicare Skilled Nursing Facility PPS, etc.
Certificates, Licenses and Registrations
Valid California Driver License.
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